Wednesday, April 16, 2014
Inquirer Daily News

Neil I. Goldfarb

POSTED: Wednesday, March 5, 2014, 6:00 AM
Filed Under: Neil I. Goldfarb

A friend of mine whom I’ll refer to as Jasper (not his real name) is a 40-something year old male who was diagnosed a few years ago with Parkinson’s disease.  Several months ago he gave me a call, knowing that I have a health benefits background.  Jasper had learned from his physical therapist that he was approaching the limits his health plan placed on the annual number of physical therapy sessions.  The physical therapist had told Jasper not to worry, when the limit was reached, the office would re-file his case under a new diagnosis, which would trigger a new benefit-eligible episode of care, allowing it to continue delivering service, billing for it, and getting reimbursed for it.

Jasper was relieved to know that clinical services that seemed to be helping him maintain his strength and physical activity would be continued, but he realized he would continue to be responsible for a 20% co-payment.  “What do you think I should do,” he asked, “should I continue with my therapy?” 

“Well, let’s start with the question of how willing you are to commit insurance fraud,” I asked.  I explained that “filing under a new diagnosis,” when in fact it was just more service addressing the same old diagnosis, was fraudulent.  Undoubtedly, being able to continue billing under a fee-for-service arrangement would benefit the provider, but I asked Jasper to think about whether the additional physical therapy visits would benefit him.

POSTED: Wednesday, January 8, 2014, 6:00 AM
Filed Under: Neil I. Goldfarb

An inaccessible, incomprehensible application website.  Health plan options that don’t seem to meet the big “A” in “ACA” (affordability) by most Americans’ definitions.  Longstanding health policies being dropped by insurers, purportedly because plans fail to meet ACA coverage requirements.  Shifting schedules for implementation, and vague and ever-changing regulations.  Mass confusion.  Take your pick, or choose them all; it seems that everyone has at least one legitimate bone to pick with “Obamacare.”

What seems to have been lost in the current acrimonious debate is why President Obama chose to go down the “health reform” path in the first place.  So, as we enter a new year, let’s recap: the U.S. healthcare system is mess, and was a mess long before Barack Obama first set his sights on the White House.  Democrats and Republicans all share in the blame for producing and perpetuating a system that overcharges, overtreats some and undertreats others, rewards poor quality, ignores safety, and fails to deliver on any of the Institute of Medicine’s six essential properties: Effectiveness, Efficiency, Timeliness, Patient-Centeredness, Equitability, and Safety. 

I understand the outrage over the ACA implementation disaster.  But, where is the outrage over 400,000 Americans dying every year in hospitals due to infections and other preventable complications of care, or spending twice as much as every other industrialized nation on health care, on a per capita basis, with nothing to show in terms of care access, quality, and health outcomes?  

POSTED: Friday, November 8, 2013, 6:00 AM
Filed Under: Neil I. Goldfarb

We’re currently at the height of “open enrollment” season – the annual period during which most employers offering health benefits to their employees roll out information on changes to the benefits plan and assist employees in making their benefit selections for the coming year.  Employees can expect to see new programs, incentives, and opportunities offered by their employers with regard to wellness program participation and achievement of wellness goals, as a result of the ACA.  Unfortunately, when it comes to the employer wellness program rules issued this summer by the US Departments of Health and Human Services, Labor, and Treasury, ACA might well stand for the Ambiguity and Confusion Act. 

According to the official Fact Sheet on the Affordable Care Act and Wellness Programs (http://www.dol.gov/ebsa/newsroom/fswellnessprogram.html), the “Act creates new incentives and builds on existing wellness program policies to promote employer wellness programs and encourage opportunities to support healthier workplaces.”  What’s not said is that the Act places employers at increased risk of litigation and expense, stifles innovation, and vitiates employers’ ability to address the population health crisis of unhealthy lifestyles.

Among key features of the rules is the distinction between “participatory” and “health-contingent” programs and incentives.  Participatory programs either do not offer a financial incentive, or link the incentive solely to participation in general aspects of the program, such as completing a health risk appraisal or attending a wellness seminar.  Health-contingent programs and incentives involve participation in a program addressing a specific health factor (e.g. weight management program) or achieving a particular outcome (e.g. losing weight or achieving normal body mass index).  There remains some ambiguity as to when a participatory program crosses the line and becomes health-contingent, even though it remains focused on participation rather than an outcome.

About this blog

The Field Clinic reports and analyzes health care laws, government policies, and political trends that are transforming the care we receive and the way we pay for it. Read more about our panel of bloggers here.

This blog is produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health-policy research and communication organization not affiliated with Kaiser Permanente. Portions of this blog may also be found on Inquirer.com and in the Inquirer's Sunday Health Section.

Follow the Field Clinic on Twitter.

RSS feed.

Robert I. Field, Ph.D., J.D., M.P.H. Professor, School of Law & Drexel School of Public Health
Jeffrey Brenner, MD Founder of the Camden Coalition of Healthcare Providers, Medical Director of the Urban Health Institute at Cooper University Healthcare
Andy Carter President & CEO, The Hospital & Healthsystem Assoc. of Pa.
Robert B. Doherty Senior Vice President of Governmental Affairs & Public Policy American College of Physicians
Neil I. Goldfarb President & CEO of the Greater Philadelphia Business Coalition on Health
David Grande, MD, MPA Assistant Professor of Medicine at the University of Pennsylvania
Tine Hansen-Turton Chief Strategy Officer of Public Health Management Corporation
Drew A. Harris, DPM, MPH Director of Health Policy Program at the Jefferson School of Population Health
Antoinette Kraus Director of the Pennsylvania Health Access Network
Laval Miller-Wilson Executive Director of the Pennsylvania Health Law Project
David B. Nash, MD, MBA Founding Dean of the Jefferson School of Population Health
Howard J. Peterson, MHA Managing Partner of TRG Healthcare, a national healthcare consulting firm
Donald Schwarz, MD, MPH Deputy Mayor for Health & Opportunity and Health Commissioner for the City of Philadelphia
Paula L. Stillman, MD, MBA Healthcare consultant with special expertise in population health and disease management
Elizabeth A. W. Williams Senior Vice President & Chief Communications Officer for Independence Blue Cross
Krystyna Dereszowska A third-year law student concentrating in health at Drexel
Also on Philly.com:
Stay Connected